Ask the Doctors October 2018 Issue

Ask The Doctors: October 2018

I have diabetes and suffered a heart attack. My doctor wants to start me on a new diabetes medication. She says it could reduce the chance of another heart attack. I have seen this medication advertised on TV and am concerned about the long list of side effects.

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When advertising a drug, pharmaceutical companies are required to list every potential adverse event reported in clinical trials. Your doctor needs to determine your risk for any of these side effects and whether the drug is right for you. We call this individualizing the treatment decision, and it involves weighing benefits against risks.

Let’s put this into perspective. The prevalence of diabetes continues to grow. Two out of three patients with diabetes die from heart disease or stroke. Over the past two decades, widespread use of statins, beta-blockers and ACE inhibitors has substantially reduced cardiovascular disease (CVD) risk. Nevertheless, the risk of stroke and heart attack is seven to eight times higher in diabetics than in non-diabetics.

In clinical trials, certain newer diabetes medications have been shown to reduce CVD events in addition to lowering blood sugar in diabetics at high risk for CVD. The GLP-1 receptor agonists liraglutide (Victoza®, Saxenda®) and semaglutide (Ozempic®), and the SGLT2 inhibitors empagliflozin (Jardiance®) and canagliflozin (Invokana®) have been shown to be superior to placebo at preventing CVD death, heart attack, stroke and heart failure in patients with known CVD. Both drug classes are associated with lower risk of symptomatic low blood sugar levels (hypoglycemia) and weight loss.

On the other hand, the DPP-4 inhibitors saxagliptin (Onglyza®), alogliptin (Nesina®) and sitagliptin (Januvia®) appear to be CVD-neutral or possibly associated with increased likelihood of heart failure.

Choosing the optimal drug depends on diabetes severity, age, kidney function, history of heart disease and cost. These newer medications may not be right for individuals with poor kidney function (GLP-1, SGLT2), dehydration or frequent urinary tract infections (SGLT2). Your doctors should work together to choose the best medication to treat your elevated blood sugar and reduce your CVD risk, as well.

I have heart disease. Do I need a flu shot?

The unequivocal answer is yes, and October and November are the ideal times to get your flu shot. Here’s why:

The 2017-2018 flu season was one of the worst in years. Hospitalizations for flu were sky high, and flu-related deaths reached epidemic proportions. Since the 1930s we have known that the flu increases the risk of death from CVD. The link between flu and CVD deaths was first suggested in the 1930s. In fact, 41 percent of people hospitalized with the flu in 2015-2016 had heart disease. One recent study found that individuals testing positive for flu were six times more likely to have a heart attack the week after their flu diagnosis than in the prior year or following year.

CVD events triggered by the flu are potentially preventable by being vaccinated against the flu. A 2013 analysis of six studies reported that flu shots reduced major CVD events by 55 percent in people who had suffered a recent heart attack or stroke. A study presented at the American College of Cardiology’s 2018 annual meeting reported a 50 percent reduction in flu-season deaths among heart-failure patients who had received the flu vaccine.

All major heart organizations recommend yearly flu shots for patients with, or at high risk for, CVD. Heed this recommendation. Even if you get the flu, it may reduce the severity of your symptoms and lessen the likelihood of a CVD event.

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